Healthcare Provider Details

I. General information

NPI: 1801462841
Provider Name (Legal Business Name): DUSTIN J KIRK PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 HIGHWAY 45
BALDWYN MS
38824-8591
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
HOOVER AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 662-365-5610
  • Fax: 662-365-5611
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-933-1996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT7097
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: